2022年 · 第135卷第03期

Chromosomal abnormalities are important causes of ventriculomegaly (VM). In mild and isolated cases of fetal VM, obstetricians rarely give clear indications for pregnancy termination. We aimed to calculate the incidence of chromosomal abnormalities and incremental yield of chromosomal microarray analysis (CMA) in VM, providing more information on genetic counseling and prognostic evaluation for fetuses with VM.

The Chinese language databases Wanfang Data, China National Knowledge Infrastructure, and China Biomedical Literature Database (from January 1, 1991 to April 29, 2020) and English language databases PubMed, Embase, and Cochrane Library (from January 1, 1945 to April 29, 2020) were systematically searched for articles on fetal VM. Diagnostic criteria were based on ultrasonographic or magnetic resonance imaging (MRI) assessment of lateral ventricular atrium width: ≥10 to <15 mm for mild VM, and ≥15 mm for severe VM. Isolated VM was defined by the absence of structural abnormalities other than VM detected by ultrasonography or MRI. R software was used for the meta-analysis to determine the incidence of chromosomal abnormalities and incremental yield of CMA in VM, and the combined rate and 95% confidence interval (CI) were calculated.

Twenty-three articles involving 1635 patients were included. The incidence of chromosomal abnormalities in VM was 9% (95% CI: 5%-12%) and incremental yield of CMA in VM was 11% (95% CI: 7%-16%). The incidences of chromosomal abnormalities in mild, severe, isolated, and non-isolated VM were 9% (95% CI: 4%-16%), 5% (95% CI: 1%-11%), 3% (95% CI: 1%-6%), and 13% (95% CI: 4%-25%), respectively.

Applying CMA in VM improved the detection rate of abnormalities. When VM is confirmed by ultrasound or MRI, obstetricians should recommend fetal karyotype analysis to exclude chromosomal abnormalities. Moreover, CMA should be recommended preferentially in pregnant women with fetal VM who are undergoing invasive prenatal diagnosis. CMA cannot completely replace chromosome karyotype analysis.

It is still unclear if and to what extent antenatal or infant or childhood vitamin D supplementation would affect the development of allergy diseases later in life. This study aimed to review the efficacy of vitamin D supplementation in pregnant women, infants, or children for the prevention of allergies.

MEDLINE (PubMed), EMBASE (OVID), and the Cochrane Central Register of Controlled Trials were searched up to March 1, 2020. We included only randomized controlled trials (RCTs). We performed a systematic review and meta-analysis for vitamin D supplementation in primary allergy prevention. These trials were assessed for risk of bias using the Cochrane Collaboration domains and the consensus was reached via discussion with the full study group. We descriptively summarized and quantitatively synthesized original data to evaluate vitamin D supplementation in primary allergy prevention by using Review Manager software for meta-analysis.

The search yielded 1251 studies. Seven RCTs were included in this analysis. A meta-analysis revealed that vitamin D supplementation for pregnant women or infants may not decrease the risk of developing allergic diseases, such as asthma or wheezing (supplementation for pregnant women, risk ratio [RR]: 1.01, 95% confidence interval [CI]: 0.81-1.26, P = 0.90, I² = 47%; supplementation for infants, RR: 1.00, 95% CI: 0.70-1.43, P = 0.99, I² = 0%; supplementation for pregnant women and infants, RR: 0.35, 95% CI: 0.10-1.25, P= 0.11), eczema (supplementation for pregnant women, RR: 0.95, 95% CI: 0.80-1.13, P= 0.77, I²= 0%; supplementation for infants, RR: 0.84, 95% CI: 0.64-1.11, P= 0.19, I²= 42%), allergic rhinitis (supplementation for pregnant women, RR: 0.93, 95% CI: 0.78-1.11, P = 0.15, I² = 47%), lower respiratory tract infection (LRTI) (supplementation for pregnant women, RR: 0.97, 95% CI: 0.85-1.11, P = 0.59, I² = 0%), or food allergy.

Supplementation of vitamin D in pregnant women or infants does not have an effect on the primary prevention of allergic diseases.

PROSPERO (CRD42020167747)

Acute pancreatitis (AP) can vary widely in its severity, from being clinically self-limiting to a rapidly fatal course.^[1]Necrotizing pancreatitis (NP) is the most serious form and is associated with a poor prognosis; the mortality rate is approximately 15%, or up to 30% for cases of infected necrotizing pancreatitis (INP), which often progresses to sepsis and multiple organ failure, the major cause of death and severe complications.^[2]The approach to the management of INP has significantly changed during the last 20 years and continues to evolve with the accumulation of experience, new techniques, and research data. Major surgical intervention and debridement were once the mainstay of therapy for patients with symptomatic necrotic foci, but a minimally invasive approach that focuses on percutaneous and/or endoscopic drainage or debridement is now favored.^[2]The "step-up" approach, which involves minimally invasive techniques, represents a new paradigm for the treatment of patients with INP, and open pancreatic debridement is now considered to be the final step in the treatment of NP.^[2]

Little was known about the association among time in range (TIR), time above range (TAR), time below range (TBR), and cancer mortality among patients with type 2 diabetes. We aimed to investigate the association among TIR, TAR, TBR, and the risk of cancer mortality among patients with type 2 diabetes.

A total of 6225 patients with type 2 diabetes were prospectively recruited in Shanghai, China. TIR was measured with continuous glucose monitoring at baseline and was defined as the average percentage of time in the target glucose range during a 24 h period. Cox proportion hazard regression analysis was used to determine the association between TIR and the risk of cancer mortality.

During a mean follow-up of 7.10 years, we confirmed 237 death events related to cancer. The multivariable-adjusted hazard ratio (HR) for cancer mortality was 1.32 (95% confidence interval [CI]: 1.01-1.75) in patients with TIR ≤70% compared with those with TIR >70%. When TIR was considered as a continuous variable, the multivariable-adjusted HR for cancer mortality associated with each 10% decrease in TIR was 1.07 (95% CI: 1.02-1.14). In the site-specific analysis, a significant association between TIR as a continuous variable and the risk of hepatocellular cancer was found (HR: 1.24; 95% CI: 1.09-1.41). However, no relationship between hemoglobin A1c and cancer mortality was observed (HR: 1.04; 95% CI: 0.97-1.10).

The present study found an inverse association of TIR with the risk of cancer mortality among patients with type 2 diabetes. New evidence of TIR was added into the clinical practice that TIR may be an optimal target of glycemic control among patients with type 2 diabetes.

Cardiovascular (CV) disease is the leading cause of morbidity and mortality in adults with type 2 diabetes (T2D). The aim of this study was to determine the CV risk in Chinese patients with T2D based on the 2019 European Society of Cardiology (ESC) and the European Association for the Study of Diabetes (EASD) guidelines on diabetes, pre-diabetes, and CV diseases.

A total of 25,411 patients with T2D, who participated in the study of China Cardiometabolic Registries 3B study, were included in our analysis. We assessed the proportions of patients in each CV risk category according to 2019 ESC/EASD guidelines.

Based on the 2019 ESC/EASD guidelines, 16,663 (65.6%), 1895 (7.5%), and 152 (0.6%) of patients were included in "very high risk," "high risk," and "moderate risk" categories, respectively. The proportions of patients in each category varied based on age, sex, body mass index, and duration. While 58.7% (9786/16,663) of elderly patients were classified to "very high risk" group, 89.6% (3732/4165) of patients with obesity were divided into "very high risk" group. Almost all patients with a duration of diabetes >10 years had "very high risk" or "high risk." However, 6701 (26.4%) of Chinese T2D patients, who had shorter duration, and one or two risk factors, could not be included in any category (the "unclear risk" category).

In China, most patients with T2D have "very high" or "high" CV risk based on 2019 ESC/EASD guidelines. However, the risk of patients in "unclear risk" group needs to be further classified.

Hepatectomy for hepatocellular carcinoma (HCC) beyond the Milan criteria is shown to be beneficial. However, a high rate of post-operative HCC recurrence hinders the long-term survival of the patients. This study aimed to investigate and compare the impacts of tenofovir (TDF) and entecavir (ETV) on the recurrence of hepatitis B viral (HBV)-related HCC beyond the Milan criteria.

Data pertaining to 1532 patients who underwent hepatectomy and received antiviral therapy between January 2014 and January 2019 were collected from five centers. Recurrence-free survival (RFS) analysis was performed using the Kaplan-Meier method. Cox proportional hazards regression analysis was performed to determine prognostic factors for HCC recurrence.

The analysis incorporates 595 HBV-related HCC patients. The overall 5-year RFS was 21.3%. Among them, 533 and 62 patients received ETV and TDF treatment, respectively. The 1-, 3-, and 5-year RFS rates were 46.3%, 27.4%, and 19.6%, respectively, in the ETV group compared with 65.1%, 41.8%, and 37.2%, respectively, in the TDF group (P < 0.001). Multivariate analysis showed that TDF treatment (hazard ratio [HR]: 0.604, P = 0.005), cirrhosis (HR: 1.557, P = 0.004), tumor size (HR: 1.037, P = 0.008), microvascular invasion (MVI) (HR: 1.403, P = 0.002), portal vein tumor thrombus (PVTT) (HR: 1.358, P = 0.012), capsular invasion (HR: 1.228, P= 0.040), and creatinine levels (CREA) (HR: 0.993, P = 0.031) were statistically significant prognostic factors associated with RFS.

Patients with HCC beyond the Milan criteria exhibited a high rate of HCC recurrence after hepatectomy. Compared to the ETV therapy, TDF administration significantly lowered the risk of HCC recurrence.

Endoscopic resection bleeding (ERB) classification was proposed by the authors’ team to evaluate the severity of intraoperative bleeding (IB) during endoscopic submucosal dissection (ESD). This study aimed to evaluate the application of ERB classification and to analyze the risk factors of major IB (MIB) and postoperative bleeding (PB) associated with ESD for gastric neoplastic lesions.

We retrospectively enrolled a total of 1334 patients who underwent ESD between November 2006 and September 2019 at The First Medical Center of Chinese People’s Liberation Army General Hospital. All patients were divided into the non-MIB group (including ERB-0, ERB-controlled 1 [ERB-c1], and ERB-c2) and the MIB group (including ERB-c3 and ERB-uncontrolled [ERB-unc]) according to the ERB classification. Risk factors of major MIB and risk factors of PB were analyzed using a logistic regression model.

Among the 1334 patients, 773 (57.95%) had ERB-0, 477 (35.76%) had ERB-c1, 77 (5.77%) had ERB-c2, 7 (0.52%) had ERB-c3, and no patients had ERB-unc. The rate of PB in patients with IB classifications of ERB-0, ERB-c1, ERB-c2, and ERB-c3 were 2.20% (17/773), 3.35% (16/477), 9.09% (7/77), and 2/7, respectively. In multivariate analysis, proximal location (odds ratio [OR]: 1.488; 95% confidence interval [CI]: 1.045-3.645; P = 0.047) was the only significant risk factor of MIB. Chronic kidney disease (CKD) (OR: 7.844; 95% CI: 1.637-37.583; P = 0.010) and MIB (ERB-c3) (OR: 13.932; 95% CI: 2.585-74.794; P = 0.002) were independent risk factors of PB.

Proximal location of lesions was a significant risk factor of MIB. Additionally, CKD and MIB (ERB-c3) were independent risk factors of PB. More attention should be paid to these high-risk patients for MIB and PB.

Vancomycin treatment failure against vancomycin-susceptible gram-positive cocci is not rare in the intensive care unit (ICU). One of the reasons for this is the substandard drug trough concentration. We aimed to examine the hypothesis that the target serum concentration could be reached earlier with a loading dose of vancomycin.

This retrospective cohort study was conducted at our ICU between June 2018 and June 2020 and involved patients who were suspected of having, or confirmed to have, gram-positive cocci infection and treated with vancomycin. One group of the patients was administered a loading dose of vancomycin (loading group) and compared with the group that did not receive a loading dose (control group). The baseline characteristics, vancomycin serum concentrations, and clinical outcomes were collected and analyzed.

Fifty-five patients were finally included, of which 29 received a loading dose of vancomycin. The serum concentration of vancomycin before the second dose was significantly higher for the loading group than for the control group (10.3 ± 6.1 mg/L vs. 5.7 ± 4.4 mg/L, P = 0.002). The results for both groups were similar before the fifth dose (12.4 ± 7.3 mg/L vs. 10.3 ± 6.3 mg/L in the loading and the control groups, respectively; P = 0.251). The 28-day mortality was lower for the loading group than for the control group (6.7% vs. 34.6% in the loading and control groups, respectively; P = 0.026). No significant differences were observed in serum creatinine (Cr) concentrations of the two groups.

With the loading dose of vancomycin, the target serum concentration of vancomycin may be reached earlier without increasing the risk of acute kidney injury.

https://www.chictr.org.cn; ChiCTR2000035369

Sweat secreted by eccrine sweat glands is transported to the skin surface through the lumen. The eccrine sweat gland develops from the initial solid bud to the final gland structure with a lumen, but how the lumen is formed and the mechanism of lumen formation have not yet been fully elucidated. This study aimed to investigate the mechanism of lumen formation of eccrine gland organoids (EGOs).

Human eccrine sweat glands were isolated from the skin for tissue culture, and the primary cultured cells were collected and cultured in Matrigel for 14 days in vitro. EGOs at different development days were collected for hematoxylin and eosin (H&E) staining to observe morphological changes and for immunofluorescence staining of proliferation marker Ki67, cellular motility marker filamentous actin (F-actin), and autophagy marker LC3B. Western blotting was used to detect the expression of Ki67, F-actin, and LC3B. Moreover, apoptosis was detected using a terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) apoptosis assay kit, and the expression of poly (ADP-ribose) polymerase and Caspase-3 was detected by Western blot. In addition, 3-methyladenine (3MA) was used as an autophagy inhibitor to detect whether the formation of sweat glands can be effectively inhibited.

The results showed that a single gland cell proliferated rapidly and formed EGOs on day 4. The earliest lumen formation was observed on day 6. From day 8 to day 14, the rate of lumen formation in EGOs increased significantly. The immunofluorescence and Western blot analyses showed that the expression of Ki67 gradually decreased with the increase in days, while the F-actin expression level did not change. Notably, the expression of autophagy marker LC3B was detected in the interior cells of EGOs as the apoptosis signal of EGOs was negative. Compared with the control group, the autophagy inhibitor 3MA can effectively limit the formation rate of the lumen and reduce the inner diameter of EGOs.

Using our model of eccrine gland 3D-reconstruction in Matrigel, we determined that autophagy rather than apoptosis plays a role in the lumen formation of EGOs.

Pathological complete response (pCR) of axillary lymph nodes (ALNs) is frequently achieved in patients with clinically node-positive breast cancer after neoadjuvant chemotherapy (NAC), and ALN status is an important prognostic factor for breast cancer patients. This study aims to develop a new predictive clinical model to assess the ALN pCR rate after NAC.

This was a retrospective series of 467 patients who had biopsy-proven positive ALNs at diagnosis and underwent ALN dissection from 2007 to 2014 at the National Cancer Center/Cancer Hospital of the Chinese Academy of Medical Sciences. We analyzed the clinicopathologic features of the patients and developed a nomogram to predict the probability of ALN pCR. A multivariable logistic regression stepwise model was used to construct a nomogram to predict ALN pCR in node-positive patients. The adjusted area under the receiver operating characteristic curve (AUC) was calculated to quantify the ability to rank patients by risk. Internal validation was performed using the 50/50 hold-out validation method. The nomogram was externally validated with prospective cohorts of 167 patients from 2016 to 2018 at the Cancer Hospital of the Chinese Academy of Medical Sciences and 114 patients from 2018 to 2020 at Beijing Tiantan Hospital.

In this retrospective study, 115 (24.6%) patients achieved ALN pCR after NAC. Multivariate analysis showed that clinical tumor stage (Odds ratio [OR]: 0.321, 95% confidence interval [CI]: 0.121-0.856; P = 0.023); primary tumor response (OR: 0.189; 95% CI: 0.123-0.292; P < 0.001), and estrogen receptor status (OR: 0.530, 95% CI: 0.304-0.925; P = 0.025) were independent predictors of ALN pCR. The nomogram was constructed based on the result of multivariate analysis. In the internal validation of performance of nomogram, the AUCs for the training and test sets were 0.719 and 0.753, respectively. The nomogram was validated in external cohorts with AUCs of 0.720, which demonstrated good discriminatory power in these data sets.

We developed a nomogram to predict the likelihood of axillary pCR in node-positive breast cancer patients after NAC. The predictive model performed well in multicenter prospective external validation. This practical tool could provide information to surgeons regarding whether to perform additional ALN dissection after NAC.

ChiCTR.org.cn, ChiCTR1800014968.

Primary malignant cardiac tumors (PMCTs) are rare but highly lethal, and up to 75% of them are sarcomas, followed by lymphoma and mesothelioma.^[1]Due to the rarity of this disease, most studies to date were small series or single case report. Although a few of them investigated the clinical characteristics and survival of PMCT patients, the factors influencing overall survival have not been well elucidated.^[2,3,4]The Surveillance, Epidemiology, and End Results (SEER) program covers about 28% of the US population, collecting data on patient demographics, primary tumor site, tumor morphology, stage at diagnosis, survival, and mortality, including rich data of cardiac tumors.^[5]In the present study, we described the clinical characteristics, identified the variables affecting the prognosis, and constructed a nomogram for patients with PMCTs using the data from the SEER database.

With an annual incidence of 0.5 to 1.5/1000, cardiac arrest (CA) has emerged as a major global public health concern.^[1]Although the American Heart Association (AHA)-International Liaison Committee on Resuscitation updates the cardiopulmonary resuscitation (CPR) guidelines every 5 years, the survival rate and percentage of patients with good neurologic outcomes post-CA after hospital discharge have been relatively low. Therefore, the AHA 2010 CPR guidelines mention the treatment of post-cardiac arrest syndrome (PCAS) in the intensive care unit (ICU) as the fifth link in the CA survival chain. PCAS is a pathophysiological process that includes (1) brain injury, (2) myocardial dysfunction leading to hemodynamic instability, and (3) systemic ischemia/reperfusion response leading to lactate accumulation.^[2]These key factors affect the survival and neurological prognosis of CA patients in the early stages. We assessed the effects of early hemodynamics, oxygen metabolism, and lactate dynamics during PCAS on a 28-day survival rate and neurological outcomes.

To the Editor:Dermatofibrosarcoma protuberans (DFSP) is a locally aggressive mesenchymal neoplasm of the skin that can be misdiagnosed as dermatofibroma (DF) because of similar histological characteristics.^[1,2,3]In this study, non-linear optical (NLO) microscopy was used for imaging unstained histological sections to make a differential diagnosis between DFSP and DF. This study aimed to demonstrate that label-free NLO imaging provides significant advantages over standard hematoxylin-eosin (H&E) staining and allows pathologists to increase the diagnostic accuracy by using a quantifiable methodology.

To the Editor:Metabolic syndrome (MetS) is defined as a set of metabolic disorders including abdominal obesity, hyperglycemia, hypertension, and dyslipidemia.^[1]As thyroid hormones are essential for cellular energy homeostasis and regulation, the levels of serum thyroid hormones are considered to be associated with various metabolic parameters. Over the past decade, the association between thyroid hormones and MetS has been extensively studied in euthyroid subjects, leading to inconsistent results. Some studies suggested that a high level of thyrotropin (TSH) contributed to the increased incidence of MetS or unfavorable metabolic parameters, whereas other studies found no such correlation. Moreover, some researches have shown that free thyroxin (FT4) levels were inversely proportional to various unfavorable metabolic parameters or MetS, while other studies suggested that FT4 levels have no such association or even a positive association with some unfavorable metabolic components after adjustment. These conflicting results may result from different designs, settings, race, exclusion criteria, adjustments, statistical analyses, and definitions of MetS and population iodine intake. Based on these, our study aimed to evaluate the association and causal relationship between thyroid hormones and MetS in people with normal thyroid function through standard epidemiological and Mendelian randomization analysis.

To the Editor: Lipohypertrophy (LH) is the most common local complication caused by multiple overlapping insulin injections. Clinically, LH manifests as prominent and/or thickened tissue at injection or infusion sites, sometimes resulting in lump formation under the skin. Histologically, LH is characterized by decreased vascularity, fibrosis, and adipocyte enlargement and proliferation in the subcutaneous tissue at insulin injection sites. Because of this, the existing screening methods for LH are mainly based on clinical examination and ultrasound scanning (USS). A recent systematic review revealed that only limited information is available for detection sensitivity among the different methods used to identify LH to date. Thus far, the gold standard examination for LH diagnosis remains debatable and there has been insufficient research on which patients require both kinds of examination. Currently, the detection sensitivity of USSvs. clinical examination for LH has not been reported in large sample-based studies. The present study aimed to compare the detection accuracy between USS and clinical examination using a large patient cohort and to determine the influencing factors for inconsistent detection results of LH between the two methods.

To the Editor:Patients with type 2 diabetes have a higher risk of cardiovascular diseases (CVD), relative to people without diabetes. Patients with diabetes always exhibit lipid abnormalities. Rapid economic development and accelerated urbanization have also led to lifestyle changes that may have an influence on the lipid parameters of Chinese patients with diabetes. Given the significant differences in socioeconomic status in China, geographical variations were also observed in the prevalence, awareness, treatment, and control of dyslipidemia among individuals who were ≥45 years old in the general Chinese population.^[1]There is a lack of large-scale studies regarding time trends and geographical variations in lipid concentrations and lipid control among Chinese adults with type 2 diabetes. Therefore, we conducted a study on time trends and geographical variations in lipid concentrations and lipid control in this population using the China National HbA1c Surveillance System (CNHSS) database of adult Chinese outpatients with type 2 diabetes during 2009 to 2013. The Ethics Committee of the Chinese People Liberation Army General Hospital approved the study protocol. Informed consent was obtained from all the patients before they were interviewed and data collected.

To the Editor: Proximal humeral fracture (PHF) predominantly occurs in patients older than 60 years old with severe osteoporosis.^[1]Although a majority of PHFs can be treated non-operatively, the complicated ones require surgical fixation.^[2]In older individuals, the loss of trabecular structure and the calcar region in the proximal humeral medullary cavity makes them prone to comminuted fracture and loss of medial hinge support, leading to a high rate of implant failure and reoperation.^[3]Recent studies have shown that endosteal augments incorporated into the locking plate construct might provide better medullary support and mechanical stability.^[1]However, the endosteal augments used in PHF fixation are of different shapes, modes, and positions, which can lead to implant failure and reduction loss.^[1,4,5]This may be because of a lack of understanding of the morphological changes that take place in the proximal humerus at different ages. Therefore, in this study, we analyzed and compared the anatomical degeneration pattern of the medullary canal between older and younger patients to have a better understanding of the medullary morphology of proximal humerus anatomically and the application of endosteal support clinically.

To the Editor: It is difficult to capture the exact time of initiation of puberty in normal children, such as when breasts in girls and testicles in boys begin to grow, especially in boys. As a result, research on the detailed patterns of physical development during puberty and the cut-off values and changes of hormones at the initiation of puberty and developmental maturation is rare. It is generally believed that hormonal changes during puberty are a direct result of the stimulating effect of luteinizing hormone (LH) on initiation of puberty;^[1]thus, LH is widely accepted as an indicator to evaluate initiation of puberty. However, researchers have not yet reached an agreement on the cut-off value of LH, especially in boys.

To the Editor: Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive, and fibrotic lung disease. The clinical processes of IPF include dyspnea, decreased lung function, and cough. The median survival time of patients with IPF is approximately 3 years. The 5-year survival rate is less than 30%.^[1]Although some progress has been made in anti-fibrotic therapy, IPF is still an incurable disease. Therefore, it is necessary to explore the pathological process of IPF from the perspective of cell biology, and these explorations can provide a basis for the treatment of IPF.

To the Editor: Coronavirus disease 2019 (COVID-19), which broke out in 2019, has become a global pandemic. Similar to severe acute respiratory syndrome coronavirus (SARS-CoV) in 2003, SARS-CoV-2 could cause acute lung injury and cytokine storms characterized by the increased interleukin (IL)-8, IL-6, and tumor necrosis factor α (TNF-α).^[1]Perspective studies in those survivors from the severe acute respiratory syndrome (SARS) epidemic in 2003 revealed that those SARS patients manifested varying degrees of pulmonary interstitial fibrosis.^[2]Similarly, patients with severe COVID-19 are also featured by the diffuse alveolar damage along with alveolar interstitial fibrosis.^[3]

To the Editor:Cryoglobulinemia is a disease characterized by cryoglobulins in serum that precipitate underin vitroconditions <37°C and redissolve on rewarming. It is divided into three types: Type I, where the cryoglobulin is composed of monoclonal IgG or IgM, and rarely IgA or free immunoglobulin (Ig) light chains; Type II, where the cryoglobulin is made of monoclonal IgM with rheumatoid factor (RF) activity and polyclonal IgG; and Type III, where the cryoglobulin is composed of polyclonal IgM with RF activity and polyclonal IgG.^[1]Types II and III are mixed cryoglobulinemia (MC). MC could be related to several infectious diseases, like hepatitis C and B. It mainly presents as cryoglobulinemic vasculitis,^[2]including fatigue, purpura, arthralgia, myalgia, peripheral neuropathy, and even severe organ damage, like glomerulonephritis. However, cryoglobulinemic vasculitis involving the gastrointestinal tract and heart is rare. Besides, neurological, ocular, and rhino-otological symptoms of hyperviscosity syndrome are also hardly seen in MC. Here, we report one hepatitis B virus (HBV)-related MC case and analyze 41 cases in literature. We have analyzed these 42 HBV-related MC cases to clarify their clinico-biological characteristics and treatment.

To the Editor: There is a high probability of requiring unplanned surgery for congenital scoliosis (CS), but very few publications have reported the proportion of unplanned surgeries, the causes of those unplanned surgeries, and the prevalence of each cause. This study aimed to provide more information regarding the above. We reviewed the electronic medical records of patients with CS that underwent unplanned surgeries at our hospital from 2009 to 2018. By searching the database of West China Hospital, we found 317 CS cases. Of these, 33 cases underwent unplanned surgeries, of which five had their primary surgeries at outside hospitals. The unplanned surgery rate in our case series was 9.0% (28/312). In our case series, the most common cause of unplanned surgery for patients with CS was progressive deformity (49%, 16/33), followed by implant-related complications (36%, 12/33), wound-related complications (12%, 4/33), and surgical error-related complications (cerebrospinal fluid [CSF] leak, 3%, 1/33). The most common reason for unplanned surgery in CS was progressive spinal deformity or imbalance, which accounted for 49% (16/33) of the unplanned surgeries.